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Tuberculosis of the Spine: A Reminder
Tuberculosis of the Spine: A Reminder* Michel Marcq, M.D.,
00
and Om P. Sharma, M.D., F.C.C.P.t
Tuberculosis of the vertebral spine is an uncommon condition in the western world. Five patients are presented to illustrate the diagnostic pitfalls and problems concerned with the diagnosis of spinal tuberculosis. A brief review of clinical features, pathogenesis, pathology, radiologic appearance and principles of therapy is presented.
Tuberculosis of the vertebrae of the spine is an uncommon condition in the United States at the present time. The infrequency of the disease often results in diagnostic oversight. We report five cases seen recently in the same hospital within a short period. CASE REPORTS CASE
1
A 48-year-old Negro housewife developed cervical pain in October, 1970. During the following months her pain worsened and radiated throughout her back. She also noticed a gradual loss of weight, generalized weakness and night sweats. Her medical history revealed pleurisy in 1957, for which she had to stay in bed for two months. In July, 1971, she attended an orthopedic clinic. Because of bone pains, anemia, hyperglobulinemia, and roentgenographic demineralization of the spine with destruction of the seventh cervical vertebrae (Fig 1), a presumptive diagnosis of multiple myeloma was made. Narrowing of adjacent intervertebral joint spaces was evident radiologically. She was admitted to the hospital. A chest x-ray examination showed normal findings and the tuberculin test (intermediate strength, 5 TU) was strongly positive. A bone scan confirmed the osteolytic lesions which were interpreted as neoplastic destruction. The patient was given a cervical collar which gave her considerable relief from pain. She was discharged in September only to be readmitted two months later with a warm, tender, fluctuating mass located in the right paraspinal area, extending to under the skin from the first to 12th thoracic vertebrae (Fig 2). This region was very tender and even minimal motions of the neck were painful. Temperature fluctuated be°From the Pulmonary Disease Section, Department of Medicine, Los Angeles County-University of Southern California Medical School, Los Angeles. oOFellow in Pulmonary Disease, combined Rancho Los Amigos Hospital and LAC-USC Medical Center, Pulmonary Disease Section and Pulmonary Fellowship Training Program. tSupported in part by the California Research Medical Education Fund of the Tuberculosis and Respiratory Disease Association of California. Reprint requests: Dr. Sharma, 2025 Zonal Avenue, Los Angeles 90033
CHEST, VOL. 63, NO.3, MARCH, 1973
tween 98° and 99.5° F in the morning and 100°-101°F in the evening. The balance of the physical examination was normal. Laboratory investigations revealed the following: hemoglobin, 9.8 gm percent; leukocyte count 10,000 cu/mm, with 54 percent segmented neutrophils, 34 percent lymphocytes, 10 percent monocytes; and 2 percent eosinophils. The cerebrospinal fluid contained no cells and its protein content was slightly elevated (73 mg percent). X-ray films of the spine showed destruction of the seventh cervical vertebrae and narrowing of the seventh-eighth thoracic intervertebral joint space. The abscess was aspirated; bacteriologic examination of the fluid revealed numerous acid-fast bacilli, and the culture grew Mycobacterium tuberculosis. The patient was transferred to the tuberculosis unit for further local and systemic treatment.
FIGURE 1. Lateral view of cervical spine showing destruction of seventh cervical vertebra. Note narrowing of intervertebral space between seventh and eighth cervical vertebrae.
403
404
MARCQ, SHARMA In February, 1969, the patient was hospitalized at the LACUSC Medical Center for persisting low back pain radiating into both thighs. On examination, flexion and rotation of the right hip evoked pain. The chest x-ray film was normal. Roentgenograms of the lumbosacral spine demonstrated a compression fracture of the 12th thoracic vertebra with narrowing of the adjacent disc spaces (Fig 3). A biopsy of the T 12 vertebra revealed regenerative osteoformation, and tissue culture yielded no acid-fast or fungus organism. In view of the patient's deteriorating condition and the negative Kveim test results, normal serum calcium levels and hand x-ray films, a diagnosis of sarcoidosis was abandoned. Corticosteroid therapy was discontinued and isoniazid maintained. The patient felt spontaneous pain in the right hip in December, 1969. A roentgenogram of the pelvis and hips was normal except for partial obliteration of the right psoas shadow. In February, 1970, the patient developed severe contracture of the right hip. An area of fullness was noted in Scarpa's triangle. Roentgenograms demonstrated narrowing of the right acetabulofemoral joint space and irregular demineralization of the femoral head. The patient was readmitted and a biopsy of the right hip was performed. A culture of synovial
FIGURE 2. Posteroanterior view of lower thoracic and lumbar spine showing fusiform abscess along lower thoracic spine.
Comment Although the patient presented with a typical clinical history, positive tuberculin test and evidence of vertebral involvement, diagnosis of spinal tuberculosis was delayed because of failure on the part of the physician to include tuberculosis in the differential diagnosis. Narrowing of the intervertebral space is a characteristic and an early roentgenographic sign of tuberculosis of the spine. It aids in differentiating spinal tuberculosis from other pathologic conditions such as metastatic carcinoma, traumatic fracture, osteomyelitis, and osteoporotic collapse from multiple myeloma. CASE
2
A 54-year-old Negro man was admitted to the hospital in May, 1968, for weakness, weight loss, and back pain of two months duration. Past and family histories were unremarkable. Physical examination findings were normal. A chest xray film showed right hilar and paratracheal adenopathy. The erythrocyte sedimentation rate was 32 mm/hr. There were 8,700 white blood cells, with 63 percent neutrophils and 6 percent band cells. The tuberculin skin test results (5 TU) were strongly positive. No acid-fast bacilli were found in the bone marrow. A scalene node biopsy showed reticulum cell hyperplasia. Liver biopsy revealed noncaseating granulomata. Acid-fast bacilli and fungal stains on the liver specimen were negative. A diagnosis of sarcoidosis was made. The patient was treated with prednisone and isoniazid.
FIGURE 3. Lateral view of dorsolumbar spine showing compression of 12th thoracic vertebra and narrowing of adjacent intervertebral spaces.
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TUBERCULOSIS OF THE SPINE fluid grew M tuberculosis. Antitubercuolsis therapy combining isoniazid, ethambutol and streptomycin was initiated. In July, 1970, right hip synovectomy and arthrotomy were performed. Full ambulation was progressively achieved. Since his discharge, the patient has been regularly seen in orthopedic and chest clinics and found to be asymptomatic and well.
Comment In this patient as in the preceding one, a diagnosis of spinal tuberculosis was not considered until a cold abscess pointed under the skin. Noncaseating granulomata in the liver may be seen in sarcoidosis, tuberculosis, brucellosis, coccidioidomycosis, primary biliary cirrhosis and in many other conditions.! Bone lesions in sarcoidosis present a typical radiologic pattern. Sites of bone lesions are phalanges of hands and feet, metacarpals, and metatarsals. The earliest changes are seen in terminal phalanges and are characterized by an increased trabecular pattern and multiple punched out Iesions.f Involvement of the vertebral column is extremely rare in sarcoidosis.f Absence of clinical and radiologic evidence of sarcoidosis in a patient with a strongly positive tuberculin test almost excludes sarcoidosis.
405 CASE
3
A 21-year-old Mexican waiter, presented at LAC-USC Medical Center in October, 1971 with a mass in the right lumbar area which had appeared over a month's time, causing him pain and discomfort on motion. He had lost his appetite and 11 pounds in weight. Physical examination findings revealed a 20 by 20 em ovoid, tender, fluctuant swelling in the right lumbar paraspinal area. During hospitalization, the patient's temperature ranged from 97.5° to 99.0° F. Hemoglobin, total and differential white cell counts were normal. The purified protein derivative (PPD) tuberculin skin test (5 TU) results were negative. The chest x-ray film was normal. X-ray films of the spine revealed narrowing of the intervertebral space between the 11th and 12th thoracic vertebra, and erosion of the vertebral bodies (Fig 4). An anteroposterior film of the abdomen showed a paraspinal mass obliterating the right psoas shadow. Purulent material from the abscess contained acid-fast bacilli and cultures grew M tuberculosis. Therapy with isoniazid, paraminosalicylic and streptomycin was instituted. Evacuation of the abscess was performed and a body jacket applied.
Comment A cold abscess was the first clinical manifestation of vertebral tuberculosis in this healthy looking man with a normal chest x-ray film. A negative tuberculin test, of course, does not ever rule out tuberculosis. CASE
4
A 24-year-old Mexican farm worker was admitted to LACUSC Medical Center with a six-month history of intermittent left thoracic pain. Dyspnea on exertion appeared two months before admission, with weakness and moderate loss of weight. He had no chills or night sweats. His history was negative except for syphillis, treated a year ago. Physical findings revealed evidence of leftsided pleural effusion. The liver was enlarged and tender, and the spleen was palpable.
FIGURE 4. Lateral view of dorsolumbar spine showing narrowing of intervertebral space between 11th and 12th thoracic vertebrae.
CHEST, VOL. 63, NO.3, MARCH, 1973
FIGURE 5. Posteroanterior chest roentgenogram showing left pleural effusion and retrocardiac mass along lower thoracic spine.
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T he wh ite cell coun t was 5,900 cu/mm, with 41 percent seg mcnted neutrnphils, 17 percent band cells and 32 percent lym phocyt es , A posteroanterior chest roentgenogram revea led left pleur al e ffusion, and a retrocardiac mass located along the thor acic intervertebral spaces (Fig 5) (eighth-ninth and nint h-tenth ) and partial destruction of adjacent vertebral bod ies. T he intermedi ate strength (5 TU) PPD skin test was negative h ut 250 T V gave a positive reaction. While in the ho .pitul, the pati ent's temperature rose to 102° F. Unsuccessful attem pts at thoracentesis were attributed to loculation of pleural fluid . A vertebral body biopsy and intervertebral space aspiration we re performed and yielded acid-fast bacilli in the pus-like fluid . A culture grew M tuberculosis organisms. T hese wen ' also found in one gastric aspirate. Therapy with isoniazid. para minosalicylate and streptomycin was begun . C o/IIIIWII I
As in use I , the paravertebral abscess was visible on the posteroanterio r chest roentgenogram as a retrocardiac density. A ca refu l search for thoracic spinal or paravertebral lesions by appropriate x-ray films of the spine should always be mad e in a patien t with back pain, fever or pleuropulmonary lesions. Th ora cic vertebrae are the bones most frequently involved in osteoar ticula r tuberculosis.
A 26-yt·ar-old M oxjcan shoemaker entered the LAC-USC Medlca l Cent rr in Novembe r, 1971, with a tender left lumbar mass wh ich had slowly increased in size during the past month . The pa tient denied fever, chills, night sweats, anorexia or weight loss. and any respiratory symptoms. His history was not significant exce pt for an episode of fatigue, fever, and sweating lastin g one month in 1969. A chest x-ray film at that time was normal. Physica l examina tion showed two mobile, nontender lymph nodes in the left axilla and an ovoid mass (10 by 5 by 6 em) in the lum bar area. partly overlying the iliac crest. The pa tient's tempe rat ure ranged from 97.8° to 99° F. T he whit e blood cell count was 10,900 per cu/mm, and the
differential count was nurmal except for occasional metamyelocytes. A chest roentgenogram showed a 2 em lung opacity in the left upper lobe, posteriorly. Sputum cultures were negative for acid-fast bacilli. The intermediate tuberculin test (5 TU) results were positive. X-ray films of the spine and pelvis were normal. A soft tissue density (Fig 6) overlying the left sacroiliac joint was visualized. Thick yellow fluid aspirated from the abscess revealed acid-fast organisms on direct examination and cultures grew M tuberculosis. The patient was started on isonazid, paraminosalicylate and streptomycin therapy.
Comment This case illustrates that even in the presence of a large paraspinal abscess, vertebral involvement may not be detectable radiologically. Paravertebral abscess formation occurs in about half of the adult patients with tuberculosis. Spondylitis and paravertebral abscess are important early signs of the disease. Bosworth- stated that a paravertebral abscess in the thoracic region was the earliest criterion for the diagnosis of spinal tuberculosis antedating bony or intervertebral disc changes. COMMENT
Tuberculosis of the spine is an uncommon conditions in the United States today. Consequently, physicians have become unaccustomed to entertaining the diagnosis. In most cases, diagnosis is readily achieved if the possibility of its existence is kept in mind. The clinical presentation together with radiologic appearance of the spine and a positive tuberculin skin test result suggesting spinal tuberculosis must be confirmed by evidence of acid-fast organisms either from the bone or body fluids. The conditions commonly confused with tuberculous disease of the spine include: pyogenic osteomyelitis, multiple myeloma, sarcoidosis, metastatic neoplasms, fungus infections, and "atypical" mycobacteriosis. In a patient with sickle cell disease, the possibility of a Salmonella abscess has to be considered. Clinical Picture
111 7 1
FIGURE 6. Lateral view of lumbosacral spine showing oval density overlying left sacroiliac joint.
The patient usually presents complaining of pain over the affected vertebrae. The pain is variable in intensity, depending upon the stage of the disease, bone destruction, and neurologic involvement. Low grade fever, chills, anorexia and weight loss may occur. Neurologic examination may reveal evidence of nerve root compression or motor paralysis. These abnormalities precede spinal deformity, especially in the cervical region. The presence of a "cold abscess" denotes advanced disease. Location of the abscess varies with the site of the lesion. Cervical tuberculosis may produce an abscess in the neck or in the supraclavicular area. Upper thoracic spinal tuberculosis may rupture into the pleura. A cold abscess due to CHEST, VOL. 63, NO.3, MARCH, 1973
407
TUBERCULOSIS OF THE SPINE lumbar involvement usually extends down the psoas sheath producing a palpable swelling in the iliac fossa, the gluteal folds or points in the groin. In four of our cases .the abscess clinically presented as a mass in the thoracic or lumbar area. A positive tuberculin skin test result supports the diagnosis; however, a negative test result should not be considered as evidence excluding tuberculous infection." In a recently reported series, 18 percent of some 115 patients with bacteriologically confirmed diagnoses failed to respond with a positive reaction to tuberculin test." In one case here reported, the intermediate tuberculin skin test result was negative. The diagnosis should always be confirmed by bacteriologic examination and culture of the material from the "cold abscess" or obtained from bone biopsy.
Radiologic Features Radiologic changes in the early stage of the disease are minimal. The lesion is rarely detected within six months of the onset of symptoms," The earliest change, visible radiologically, is a slight rarefaction of the superior or inferior aspect of a vertebral body, anteriorly. There may be some decalcification of the central body. Narrowing or thinning of the intervertebral space may also occur in the early stages. In advanced stages, destruction and wedging of one or more vertebral bodies may occur. Destruction of the disc and narrowing of the intervertebral space serves to differentiate tuberculosis from other conditions such as neoplasm, sarcoidosis and nontuberculous infections. Progressive vertebral collapse may result in kyphosis and gibbbus formation. In the cervical area the cold abscess spreads from the anterior aspects of the vertebral bodies, pushing the trachea and esophagus forward. In the thoracic region, a cold abscess appears as a fusiform density along the spine or a paraspinal abscess. Calcification within the abscess is pathognomonic of tuberculosis.
Pathogenesis The respiratory tract is the route of entry of tubercle bacilli in most cases. In an analysis of 500 cases with skeletal tuberculosis, Mann" found active pulmonary tuberculosis in 57 percent of patients. In children the skeletal lesion starts soon after the initial infection, and is usually due to hematogenous seeding of the vertebral body. The disease process usually begins in the metaphysial portions of the epiphyses, the areas richest in the blood supply." In adults reactivation of a quiescent tuberculous focus may result in blood stream dissemination and CHEST, VOL. 63, NO.3, MARCH, 1973
metastasis to bones. Burke'? contends that Pott's disease is, in many instances, a lymph-borne sequela of tuberculous pleuritis. The tubercle bacilli from the pleural space migrate to para-aortic lymph glands producing necrosis and caseation. The disease process then spreads to the vertebral column either by contiguity or by way of connecting lymphatics. Clinical tuberculous pleurisy may precede or accompany vertebral spinal tuberculosis.
Pathology Key described three types of vertebral involvement: central, anterior or epiphysial, depending upon the apparent initial site of infection." In children, tuberculosis of the spine starts as osteomyelitis and in adults, as periostitis. This difference depends upon the vascular anatomy; in children the main vascular trunk, a branch of the posterior spine, enters the vertebral body posteriorly. In the adult the principal blood supply is from intercostal and lumbar arteries, entering anteriorly and branching out subperiosteally.? The involvement of anterior aspects of vertebral bodies also depends upon this anatomic arrangement. Vertebral tuberculosis spreads to the intervertebral discs, longitudinal spinal ligaments and soft tissues. In children, the upper thoracic spine is involved commonly; in adults, lower dorsal and lumbar regions are involved more frequently. Destruction of the vertebral bodies results in collapse and subsequent gibbus. Spinal cord involvement may occur at any time, even in cases that seemed to have healed. The usual cause of cord damage is compression due to abscess or a granulomatous mass. Occasionally, dislocation of a vertebral body or backward displacement of a sequestrum may result in acute compression.
Treatment The modem management of spinal tuberculosis demands joint supervision by a team comprising the chest physician, orthopedic surgeon, neurologist and physical therapist. There is no one mode of therapy or one operation for spinal tuberculosis. The choice of procedure depends upon the age and general condition of the patient, activity of the disease, extent of tissue destruction, presence or absence of neurologic lesions and the socioeconomic and cultural background of the patient. 12- 15 In the early stages, arrest of the disease and good joint function can be expected to occur with an effective combination of antituberculosis chemotherapeutic agents: three drugs given for a minimum period of three years. Immobilization of the involved region
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is extremely important." Chemotherapy by itself has little effect on advanced bony disease with destruction. Here surgical treatment includes spinal fusion." If the patient has neurologic involvement, evacuation of the cavity, removal of the bony sequestra and anterior spinal fusion is the method of choice." Posterior fusion has its place in the management of patients with neurologic involvement." ACKNOWLEDGMENT: We are deeply indebted to Oscar Balchum, M.D., Ph.D., Hastings Professor of Medicine, University of Southern California School of Medicine, Los Angeles, for the guidance and valuable advice in preparing this manuscript.
J.
REFERENCES
1 Sharma OP, James DC: Differential diagnosis of sarcoidosis. Practitioner 202:619, 1969 2 Sharma OP, Bailey AR, Carstairs LS, James DC: Bone involvement in sarcoidosis. Fifth Int'l. Conf. on Sarcoidosis: (Levinsky L, Macholda F eds) Prague, Charles University, 1971, pp 594 3 Rodman R, Funderback EE, [r, Myerson RM: Sarcoidosis with vertebral involvement. Ann Intern Med 50:213, 1959 4 Bosworth DM: Tuberculosis of the spine. J Bone Joint Surg 27:491,1945 5 Sharma OP, Evans PA: Negative tuberculin test in active tuberculosis. N Engl J Med 286:374, 1972 6 Holden M, Dubin MR, Diamond MH: Frequency of negative intermediate-strength tuberculin sensitivity in patients with active tuberculosis. N Engl J Moo 285:
1506, 1971 7 Epstein BS: The Spine: Radiological Test and Atlas. Philadelphia, Lea and Febiger, 1962, pp 256 8 Mann KJ: Lung lesions in skeletal tuberculosis: review of 500 cases. Lancet 2:744, 1946 9 Lincoln EM, Sewall EM: Tuberculosis in Children. (Chap 10), New York, McGraw-Hill Book Co, 1963 10 Burke EH: The pathogenesis of certain forms of extrapulmonary tuberculosis: spontaneous cold abscess of the chest wall and pott's disease. Am Rev Tuberc 62:48, 1950 11 Key JA: Pathology of tuberculosis of spine. J Bone Joint Surg 30-A:302, 1948 12 Hodgson AR, Stock FE: Anterior spine fusion in the treatment of tuberculosis of the spine: the operative findings and results of treatment in the first 100 cases. J Bone Joint Surg 42-A:295, 1960 13 Roaf R, Kirkaldy-Willis WH, Cathro AJM: Surgical Treatment of Bone and Joint Tuberculosis. Baltimore, Williams and Wilkins, 1959, pp 137 14 Bosworth DM: Treatment of tuberculosis of bone and joint. Bull NY Acad Med 35:167,1959 15 Katayama R, Itami Y, Marurno E: Treatment of hip and knee-joint tuberculosis. J Bone Joint Surg 44-A:897, 1962 16 The present status of skeletal tuberculosis. A statement of the subcommittee on therapy. Am Rev Resp Dis 88:272, 1963 17 Girdlesone GR: The operative treatment of Pott's paraplegia. Br J Surg 19: 121, 1931 18 Tuli RS: Treatment of neurological complications in tuberculosis of the spine. J Bone Joint Surg 51-A:680, 1969 19 Hoover NW: Skeletal tuberculosis. In Clinical Tuberculosis, ( Pfuetze, KH, ed) Springfield, Il, CC Thomas, 1966, pp 299-305
CHEST, VOL. 63, NO.3, MARCH, 1973
00
and Om P. Sharma, M.D., F.C.C.P.t
Tuberculosis of the vertebral spine is an uncommon condition in the western world. Five patients are presented to illustrate the diagnostic pitfalls and problems concerned with the diagnosis of spinal tuberculosis. A brief review of clinical features, pathogenesis, pathology, radiologic appearance and principles of therapy is presented.
Tuberculosis of the vertebrae of the spine is an uncommon condition in the United States at the present time. The infrequency of the disease often results in diagnostic oversight. We report five cases seen recently in the same hospital within a short period. CASE REPORTS CASE
1
A 48-year-old Negro housewife developed cervical pain in October, 1970. During the following months her pain worsened and radiated throughout her back. She also noticed a gradual loss of weight, generalized weakness and night sweats. Her medical history revealed pleurisy in 1957, for which she had to stay in bed for two months. In July, 1971, she attended an orthopedic clinic. Because of bone pains, anemia, hyperglobulinemia, and roentgenographic demineralization of the spine with destruction of the seventh cervical vertebrae (Fig 1), a presumptive diagnosis of multiple myeloma was made. Narrowing of adjacent intervertebral joint spaces was evident radiologically. She was admitted to the hospital. A chest x-ray examination showed normal findings and the tuberculin test (intermediate strength, 5 TU) was strongly positive. A bone scan confirmed the osteolytic lesions which were interpreted as neoplastic destruction. The patient was given a cervical collar which gave her considerable relief from pain. She was discharged in September only to be readmitted two months later with a warm, tender, fluctuating mass located in the right paraspinal area, extending to under the skin from the first to 12th thoracic vertebrae (Fig 2). This region was very tender and even minimal motions of the neck were painful. Temperature fluctuated be°From the Pulmonary Disease Section, Department of Medicine, Los Angeles County-University of Southern California Medical School, Los Angeles. oOFellow in Pulmonary Disease, combined Rancho Los Amigos Hospital and LAC-USC Medical Center, Pulmonary Disease Section and Pulmonary Fellowship Training Program. tSupported in part by the California Research Medical Education Fund of the Tuberculosis and Respiratory Disease Association of California. Reprint requests: Dr. Sharma, 2025 Zonal Avenue, Los Angeles 90033
CHEST, VOL. 63, NO.3, MARCH, 1973
tween 98° and 99.5° F in the morning and 100°-101°F in the evening. The balance of the physical examination was normal. Laboratory investigations revealed the following: hemoglobin, 9.8 gm percent; leukocyte count 10,000 cu/mm, with 54 percent segmented neutrophils, 34 percent lymphocytes, 10 percent monocytes; and 2 percent eosinophils. The cerebrospinal fluid contained no cells and its protein content was slightly elevated (73 mg percent). X-ray films of the spine showed destruction of the seventh cervical vertebrae and narrowing of the seventh-eighth thoracic intervertebral joint space. The abscess was aspirated; bacteriologic examination of the fluid revealed numerous acid-fast bacilli, and the culture grew Mycobacterium tuberculosis. The patient was transferred to the tuberculosis unit for further local and systemic treatment.
FIGURE 1. Lateral view of cervical spine showing destruction of seventh cervical vertebra. Note narrowing of intervertebral space between seventh and eighth cervical vertebrae.
403
404
MARCQ, SHARMA In February, 1969, the patient was hospitalized at the LACUSC Medical Center for persisting low back pain radiating into both thighs. On examination, flexion and rotation of the right hip evoked pain. The chest x-ray film was normal. Roentgenograms of the lumbosacral spine demonstrated a compression fracture of the 12th thoracic vertebra with narrowing of the adjacent disc spaces (Fig 3). A biopsy of the T 12 vertebra revealed regenerative osteoformation, and tissue culture yielded no acid-fast or fungus organism. In view of the patient's deteriorating condition and the negative Kveim test results, normal serum calcium levels and hand x-ray films, a diagnosis of sarcoidosis was abandoned. Corticosteroid therapy was discontinued and isoniazid maintained. The patient felt spontaneous pain in the right hip in December, 1969. A roentgenogram of the pelvis and hips was normal except for partial obliteration of the right psoas shadow. In February, 1970, the patient developed severe contracture of the right hip. An area of fullness was noted in Scarpa's triangle. Roentgenograms demonstrated narrowing of the right acetabulofemoral joint space and irregular demineralization of the femoral head. The patient was readmitted and a biopsy of the right hip was performed. A culture of synovial
FIGURE 2. Posteroanterior view of lower thoracic and lumbar spine showing fusiform abscess along lower thoracic spine.
Comment Although the patient presented with a typical clinical history, positive tuberculin test and evidence of vertebral involvement, diagnosis of spinal tuberculosis was delayed because of failure on the part of the physician to include tuberculosis in the differential diagnosis. Narrowing of the intervertebral space is a characteristic and an early roentgenographic sign of tuberculosis of the spine. It aids in differentiating spinal tuberculosis from other pathologic conditions such as metastatic carcinoma, traumatic fracture, osteomyelitis, and osteoporotic collapse from multiple myeloma. CASE
2
A 54-year-old Negro man was admitted to the hospital in May, 1968, for weakness, weight loss, and back pain of two months duration. Past and family histories were unremarkable. Physical examination findings were normal. A chest xray film showed right hilar and paratracheal adenopathy. The erythrocyte sedimentation rate was 32 mm/hr. There were 8,700 white blood cells, with 63 percent neutrophils and 6 percent band cells. The tuberculin skin test results (5 TU) were strongly positive. No acid-fast bacilli were found in the bone marrow. A scalene node biopsy showed reticulum cell hyperplasia. Liver biopsy revealed noncaseating granulomata. Acid-fast bacilli and fungal stains on the liver specimen were negative. A diagnosis of sarcoidosis was made. The patient was treated with prednisone and isoniazid.
FIGURE 3. Lateral view of dorsolumbar spine showing compression of 12th thoracic vertebra and narrowing of adjacent intervertebral spaces.
CHEST, VOL. 63, NO, 3, MARCH, 1973
TUBERCULOSIS OF THE SPINE fluid grew M tuberculosis. Antitubercuolsis therapy combining isoniazid, ethambutol and streptomycin was initiated. In July, 1970, right hip synovectomy and arthrotomy were performed. Full ambulation was progressively achieved. Since his discharge, the patient has been regularly seen in orthopedic and chest clinics and found to be asymptomatic and well.
Comment In this patient as in the preceding one, a diagnosis of spinal tuberculosis was not considered until a cold abscess pointed under the skin. Noncaseating granulomata in the liver may be seen in sarcoidosis, tuberculosis, brucellosis, coccidioidomycosis, primary biliary cirrhosis and in many other conditions.! Bone lesions in sarcoidosis present a typical radiologic pattern. Sites of bone lesions are phalanges of hands and feet, metacarpals, and metatarsals. The earliest changes are seen in terminal phalanges and are characterized by an increased trabecular pattern and multiple punched out Iesions.f Involvement of the vertebral column is extremely rare in sarcoidosis.f Absence of clinical and radiologic evidence of sarcoidosis in a patient with a strongly positive tuberculin test almost excludes sarcoidosis.
405 CASE
3
A 21-year-old Mexican waiter, presented at LAC-USC Medical Center in October, 1971 with a mass in the right lumbar area which had appeared over a month's time, causing him pain and discomfort on motion. He had lost his appetite and 11 pounds in weight. Physical examination findings revealed a 20 by 20 em ovoid, tender, fluctuant swelling in the right lumbar paraspinal area. During hospitalization, the patient's temperature ranged from 97.5° to 99.0° F. Hemoglobin, total and differential white cell counts were normal. The purified protein derivative (PPD) tuberculin skin test (5 TU) results were negative. The chest x-ray film was normal. X-ray films of the spine revealed narrowing of the intervertebral space between the 11th and 12th thoracic vertebra, and erosion of the vertebral bodies (Fig 4). An anteroposterior film of the abdomen showed a paraspinal mass obliterating the right psoas shadow. Purulent material from the abscess contained acid-fast bacilli and cultures grew M tuberculosis. Therapy with isoniazid, paraminosalicylic and streptomycin was instituted. Evacuation of the abscess was performed and a body jacket applied.
Comment A cold abscess was the first clinical manifestation of vertebral tuberculosis in this healthy looking man with a normal chest x-ray film. A negative tuberculin test, of course, does not ever rule out tuberculosis. CASE
4
A 24-year-old Mexican farm worker was admitted to LACUSC Medical Center with a six-month history of intermittent left thoracic pain. Dyspnea on exertion appeared two months before admission, with weakness and moderate loss of weight. He had no chills or night sweats. His history was negative except for syphillis, treated a year ago. Physical findings revealed evidence of leftsided pleural effusion. The liver was enlarged and tender, and the spleen was palpable.
FIGURE 4. Lateral view of dorsolumbar spine showing narrowing of intervertebral space between 11th and 12th thoracic vertebrae.
CHEST, VOL. 63, NO.3, MARCH, 1973
FIGURE 5. Posteroanterior chest roentgenogram showing left pleural effusion and retrocardiac mass along lower thoracic spine.
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T he wh ite cell coun t was 5,900 cu/mm, with 41 percent seg mcnted neutrnphils, 17 percent band cells and 32 percent lym phocyt es , A posteroanterior chest roentgenogram revea led left pleur al e ffusion, and a retrocardiac mass located along the thor acic intervertebral spaces (Fig 5) (eighth-ninth and nint h-tenth ) and partial destruction of adjacent vertebral bod ies. T he intermedi ate strength (5 TU) PPD skin test was negative h ut 250 T V gave a positive reaction. While in the ho .pitul, the pati ent's temperature rose to 102° F. Unsuccessful attem pts at thoracentesis were attributed to loculation of pleural fluid . A vertebral body biopsy and intervertebral space aspiration we re performed and yielded acid-fast bacilli in the pus-like fluid . A culture grew M tuberculosis organisms. T hese wen ' also found in one gastric aspirate. Therapy with isoniazid. para minosalicylate and streptomycin was begun . C o/IIIIWII I
As in use I , the paravertebral abscess was visible on the posteroanterio r chest roentgenogram as a retrocardiac density. A ca refu l search for thoracic spinal or paravertebral lesions by appropriate x-ray films of the spine should always be mad e in a patien t with back pain, fever or pleuropulmonary lesions. Th ora cic vertebrae are the bones most frequently involved in osteoar ticula r tuberculosis.
A 26-yt·ar-old M oxjcan shoemaker entered the LAC-USC Medlca l Cent rr in Novembe r, 1971, with a tender left lumbar mass wh ich had slowly increased in size during the past month . The pa tient denied fever, chills, night sweats, anorexia or weight loss. and any respiratory symptoms. His history was not significant exce pt for an episode of fatigue, fever, and sweating lastin g one month in 1969. A chest x-ray film at that time was normal. Physica l examina tion showed two mobile, nontender lymph nodes in the left axilla and an ovoid mass (10 by 5 by 6 em) in the lum bar area. partly overlying the iliac crest. The pa tient's tempe rat ure ranged from 97.8° to 99° F. T he whit e blood cell count was 10,900 per cu/mm, and the
differential count was nurmal except for occasional metamyelocytes. A chest roentgenogram showed a 2 em lung opacity in the left upper lobe, posteriorly. Sputum cultures were negative for acid-fast bacilli. The intermediate tuberculin test (5 TU) results were positive. X-ray films of the spine and pelvis were normal. A soft tissue density (Fig 6) overlying the left sacroiliac joint was visualized. Thick yellow fluid aspirated from the abscess revealed acid-fast organisms on direct examination and cultures grew M tuberculosis. The patient was started on isonazid, paraminosalicylate and streptomycin therapy.
Comment This case illustrates that even in the presence of a large paraspinal abscess, vertebral involvement may not be detectable radiologically. Paravertebral abscess formation occurs in about half of the adult patients with tuberculosis. Spondylitis and paravertebral abscess are important early signs of the disease. Bosworth- stated that a paravertebral abscess in the thoracic region was the earliest criterion for the diagnosis of spinal tuberculosis antedating bony or intervertebral disc changes. COMMENT
Tuberculosis of the spine is an uncommon conditions in the United States today. Consequently, physicians have become unaccustomed to entertaining the diagnosis. In most cases, diagnosis is readily achieved if the possibility of its existence is kept in mind. The clinical presentation together with radiologic appearance of the spine and a positive tuberculin skin test result suggesting spinal tuberculosis must be confirmed by evidence of acid-fast organisms either from the bone or body fluids. The conditions commonly confused with tuberculous disease of the spine include: pyogenic osteomyelitis, multiple myeloma, sarcoidosis, metastatic neoplasms, fungus infections, and "atypical" mycobacteriosis. In a patient with sickle cell disease, the possibility of a Salmonella abscess has to be considered. Clinical Picture
111 7 1
FIGURE 6. Lateral view of lumbosacral spine showing oval density overlying left sacroiliac joint.
The patient usually presents complaining of pain over the affected vertebrae. The pain is variable in intensity, depending upon the stage of the disease, bone destruction, and neurologic involvement. Low grade fever, chills, anorexia and weight loss may occur. Neurologic examination may reveal evidence of nerve root compression or motor paralysis. These abnormalities precede spinal deformity, especially in the cervical region. The presence of a "cold abscess" denotes advanced disease. Location of the abscess varies with the site of the lesion. Cervical tuberculosis may produce an abscess in the neck or in the supraclavicular area. Upper thoracic spinal tuberculosis may rupture into the pleura. A cold abscess due to CHEST, VOL. 63, NO.3, MARCH, 1973
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TUBERCULOSIS OF THE SPINE lumbar involvement usually extends down the psoas sheath producing a palpable swelling in the iliac fossa, the gluteal folds or points in the groin. In four of our cases .the abscess clinically presented as a mass in the thoracic or lumbar area. A positive tuberculin skin test result supports the diagnosis; however, a negative test result should not be considered as evidence excluding tuberculous infection." In a recently reported series, 18 percent of some 115 patients with bacteriologically confirmed diagnoses failed to respond with a positive reaction to tuberculin test." In one case here reported, the intermediate tuberculin skin test result was negative. The diagnosis should always be confirmed by bacteriologic examination and culture of the material from the "cold abscess" or obtained from bone biopsy.
Radiologic Features Radiologic changes in the early stage of the disease are minimal. The lesion is rarely detected within six months of the onset of symptoms," The earliest change, visible radiologically, is a slight rarefaction of the superior or inferior aspect of a vertebral body, anteriorly. There may be some decalcification of the central body. Narrowing or thinning of the intervertebral space may also occur in the early stages. In advanced stages, destruction and wedging of one or more vertebral bodies may occur. Destruction of the disc and narrowing of the intervertebral space serves to differentiate tuberculosis from other conditions such as neoplasm, sarcoidosis and nontuberculous infections. Progressive vertebral collapse may result in kyphosis and gibbbus formation. In the cervical area the cold abscess spreads from the anterior aspects of the vertebral bodies, pushing the trachea and esophagus forward. In the thoracic region, a cold abscess appears as a fusiform density along the spine or a paraspinal abscess. Calcification within the abscess is pathognomonic of tuberculosis.
Pathogenesis The respiratory tract is the route of entry of tubercle bacilli in most cases. In an analysis of 500 cases with skeletal tuberculosis, Mann" found active pulmonary tuberculosis in 57 percent of patients. In children the skeletal lesion starts soon after the initial infection, and is usually due to hematogenous seeding of the vertebral body. The disease process usually begins in the metaphysial portions of the epiphyses, the areas richest in the blood supply." In adults reactivation of a quiescent tuberculous focus may result in blood stream dissemination and CHEST, VOL. 63, NO.3, MARCH, 1973
metastasis to bones. Burke'? contends that Pott's disease is, in many instances, a lymph-borne sequela of tuberculous pleuritis. The tubercle bacilli from the pleural space migrate to para-aortic lymph glands producing necrosis and caseation. The disease process then spreads to the vertebral column either by contiguity or by way of connecting lymphatics. Clinical tuberculous pleurisy may precede or accompany vertebral spinal tuberculosis.
Pathology Key described three types of vertebral involvement: central, anterior or epiphysial, depending upon the apparent initial site of infection." In children, tuberculosis of the spine starts as osteomyelitis and in adults, as periostitis. This difference depends upon the vascular anatomy; in children the main vascular trunk, a branch of the posterior spine, enters the vertebral body posteriorly. In the adult the principal blood supply is from intercostal and lumbar arteries, entering anteriorly and branching out subperiosteally.? The involvement of anterior aspects of vertebral bodies also depends upon this anatomic arrangement. Vertebral tuberculosis spreads to the intervertebral discs, longitudinal spinal ligaments and soft tissues. In children, the upper thoracic spine is involved commonly; in adults, lower dorsal and lumbar regions are involved more frequently. Destruction of the vertebral bodies results in collapse and subsequent gibbus. Spinal cord involvement may occur at any time, even in cases that seemed to have healed. The usual cause of cord damage is compression due to abscess or a granulomatous mass. Occasionally, dislocation of a vertebral body or backward displacement of a sequestrum may result in acute compression.
Treatment The modem management of spinal tuberculosis demands joint supervision by a team comprising the chest physician, orthopedic surgeon, neurologist and physical therapist. There is no one mode of therapy or one operation for spinal tuberculosis. The choice of procedure depends upon the age and general condition of the patient, activity of the disease, extent of tissue destruction, presence or absence of neurologic lesions and the socioeconomic and cultural background of the patient. 12- 15 In the early stages, arrest of the disease and good joint function can be expected to occur with an effective combination of antituberculosis chemotherapeutic agents: three drugs given for a minimum period of three years. Immobilization of the involved region
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is extremely important." Chemotherapy by itself has little effect on advanced bony disease with destruction. Here surgical treatment includes spinal fusion." If the patient has neurologic involvement, evacuation of the cavity, removal of the bony sequestra and anterior spinal fusion is the method of choice." Posterior fusion has its place in the management of patients with neurologic involvement." ACKNOWLEDGMENT: We are deeply indebted to Oscar Balchum, M.D., Ph.D., Hastings Professor of Medicine, University of Southern California School of Medicine, Los Angeles, for the guidance and valuable advice in preparing this manuscript.
J.
REFERENCES
1 Sharma OP, James DC: Differential diagnosis of sarcoidosis. Practitioner 202:619, 1969 2 Sharma OP, Bailey AR, Carstairs LS, James DC: Bone involvement in sarcoidosis. Fifth Int'l. Conf. on Sarcoidosis: (Levinsky L, Macholda F eds) Prague, Charles University, 1971, pp 594 3 Rodman R, Funderback EE, [r, Myerson RM: Sarcoidosis with vertebral involvement. Ann Intern Med 50:213, 1959 4 Bosworth DM: Tuberculosis of the spine. J Bone Joint Surg 27:491,1945 5 Sharma OP, Evans PA: Negative tuberculin test in active tuberculosis. N Engl J Med 286:374, 1972 6 Holden M, Dubin MR, Diamond MH: Frequency of negative intermediate-strength tuberculin sensitivity in patients with active tuberculosis. N Engl J Moo 285:
1506, 1971 7 Epstein BS: The Spine: Radiological Test and Atlas. Philadelphia, Lea and Febiger, 1962, pp 256 8 Mann KJ: Lung lesions in skeletal tuberculosis: review of 500 cases. Lancet 2:744, 1946 9 Lincoln EM, Sewall EM: Tuberculosis in Children. (Chap 10), New York, McGraw-Hill Book Co, 1963 10 Burke EH: The pathogenesis of certain forms of extrapulmonary tuberculosis: spontaneous cold abscess of the chest wall and pott's disease. Am Rev Tuberc 62:48, 1950 11 Key JA: Pathology of tuberculosis of spine. J Bone Joint Surg 30-A:302, 1948 12 Hodgson AR, Stock FE: Anterior spine fusion in the treatment of tuberculosis of the spine: the operative findings and results of treatment in the first 100 cases. J Bone Joint Surg 42-A:295, 1960 13 Roaf R, Kirkaldy-Willis WH, Cathro AJM: Surgical Treatment of Bone and Joint Tuberculosis. Baltimore, Williams and Wilkins, 1959, pp 137 14 Bosworth DM: Treatment of tuberculosis of bone and joint. Bull NY Acad Med 35:167,1959 15 Katayama R, Itami Y, Marurno E: Treatment of hip and knee-joint tuberculosis. J Bone Joint Surg 44-A:897, 1962 16 The present status of skeletal tuberculosis. A statement of the subcommittee on therapy. Am Rev Resp Dis 88:272, 1963 17 Girdlesone GR: The operative treatment of Pott's paraplegia. Br J Surg 19: 121, 1931 18 Tuli RS: Treatment of neurological complications in tuberculosis of the spine. J Bone Joint Surg 51-A:680, 1969 19 Hoover NW: Skeletal tuberculosis. In Clinical Tuberculosis, ( Pfuetze, KH, ed) Springfield, Il, CC Thomas, 1966, pp 299-305
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